Health Questionnaire – 6 to 11 Health Questionnaire - 6 to 11 Personal Details Title * Name * Name First First Last Last Date of Birth * Gender * Male Female Non-binary Address * Address House name / Flat No House name / Flat No Street address Street address Postcode Postcode City City Country AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCôte d'IvoireCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthelemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Who else lives in your household? * Is your child the lone or partial carer for someone? * Yes No If yes, please specify HOME Phone Number Do you consent to have messages about your child left on voicemail? Yes No Email Address * Do you consent to use of your email as a way for us to contact you about your child? * Yes No Owner of address? * MOBILE Phone number Do you consent to have messages about your child left on voicemail? Yes No Owner of mobile? * Next of Kin * Medication Is your child on any regular medication? * Yes No ***** (Please note that you need to see a GP, if on existing medication, for a first repeat prescription to be issued. Make an appointment with a GP for a review of your medication in good time and before you run out!) ***** Please state name and dose of all their current medications Is your child allergic to any medications? * Yes No If yes, please state name of medication and type of reaction they had Medical History Has your child had/still have any of the following conditions: High Blood Pressure * Yes No Approx date of diagnosis: Diabetes * Yes No Approx date of diagnosis: Heart Disease * Yes No Approx date of diagnosis: Angina * Yes No Approx date of diagnosis: Epilepsy * Yes No Approx date of diagnosis: Stroke * Yes No Approx date of diagnosis: Cancer * Yes No Approx date of diagnosis: Asthma * Yes No Approx date of diagnosis: If asthmatic, have you used your inhaler in the last 12 months? Yes No Please give details of any other illnesses, accidents, hospital admissions, investigations or operations your child has had: Family History Has a first degree relative (parent or sibling) of your child suffered from any of the following conditions? Cancer * Yes No Who? At what age? Stroke * Yes No Who? At what age? Heart Disease * Yes No Who? At what age? Diabetes * Yes No Who? At what age? Do any other illnesses run in you family? * Yes No If yes, please give details: Contact with Other Agencies Under the current Child Health & Wellbeing Guidance, we are obliged to ask the following for all new registrations to the Practice between the ages of 0-16 years. Does anyone in your household currently have contact with any of the following support services? A: Social Word Department * Yes No B: Mental Health Services * Yes No C: Drug/Alcohol Support Services * Yes No If yes to any, please give brief details Ethnicity & Language What is your child's main spoken language? * Do they need an interpreter or sign language support? * Yes No Choose ONE section from A to G then choose ONE option which best describes your child's ethnic group or background A: White Scottish English Welsh Northern Irish British Irish Gypsy/Traveller Polish OtherOther B: Mixed or multiple ethnic groups Any mixed or multiple ethnic groupAny mixed or multiple ethnic group C: Asian, Asian Scottish, or Asian British Pakistani, Pakistani Scottish, or Pakistani British Indian, Indian Scottish or Indian British Bangladeshi, Bangladeshi Scottish, or Bangladeshi British Chinese, Chinese Scottish, or Chinese British OtherOther D: African African, African Scottish, or African British OtherOther E: Caribbean or Black Caribbean, Caribbean Scottish, or Caribbean British Black, Black Scottish, Black British OtherOther F: Other ethnic group Arab OtherOther G: Other I would prefer not to say I don't know their ethnicity Confirmation I confirm that I have read and understood this form, and completed it honestly and to the best of my knowledge * Confirm Your Name * Your Name First First Last Last Relationship to the child? * reCAPTCHA Submit Start Over Δ
